New Visit

patient

Patient Name:

Phone number:

PD of patient:

visits:

Date of visit:: 2/3/2025 3:35:00 PM
Cost:: 20
Service:: Change Lenses ONLY
prescribed by doctor:: Old RX
Notes:: AR Lenses

	SPH	CYL	AX	ADD
OD	-2	-0.25	110
OS	-2.25

Date of visit:: 6/10/2025 4:31:00 PM
Cost:: 35
Service:: change lenses
prescribed by doctor:: Old RX
Notes:: AR transition,

	SPH	CYL	AX	ADD
OD	-2	-0.25	110
OS	-2.25

New visit Information

Date of visit:

Cost in this visit:

type of service:

prescribed by doctor

Note:

	SPH	CYL	AX	ADD
OD
OS